Sunflower Clinic

Sunflower Clinic

Consent for Telehealth / Teletherapy Services

Last updated June 8, 2026

I understand that Sunflower Clinic offers mental health and substance use treatment through telehealth, including individual therapy and other clinical or supportive services delivered via secure video and electronic communication using the Healthie telehealth platform or similar technologies.

These services may include psychotherapy, assessments, care coordination, psychoeducation, or other services that may be introduced in the future and delivered in whole or in part through telehealth.

Telehealth involves the use of interactive audio and video technology that allows me to communicate with my provider remotely rather than in person. My provider has explained how telehealth will be used in my care and how we will connect while working together.

Potential Risks of Telehealth

I understand that there are potential risks associated with the use of telehealth technology, including but not limited to:

  • Technology failures, such as interruptions, delays, or disconnections during sessions
  • Poor audio or video quality that may limit communication
  • Security risks inherent in electronic communication, despite reasonable safeguards

Telehealth may not be appropriate for all conditions, symptoms, or clinical situations, and in-person services or a higher level of care may be recommended based on my provider’s clinical judgment.

I understand that if technical issues arise, my provider and I may need to reconnect, reschedule, or use an alternative method of communication.

Benefits of Telehealth

I understand that the potential benefits of telehealth services include:

  • Increased access to care without the need to travel
  • Greater flexibility in scheduling
  • Continued access to care regardless of geographic location
  • The ability to receive services in a familiar and comfortable environment

Confidentiality and Privacy

I understand that telehealth sessions are conducted using the Healthie platform, which uses reasonable administrative, technical, and physical safeguards to protect the confidentiality of my protected health information.

I understand that, as with any electronic communication, there is a risk of unauthorized access despite best efforts to maintain privacy. I agree to participate in sessions from a private location and to take reasonable steps on my end to protect my confidentiality. This includes using a secure internet connection, ensuring others cannot overhear sessions, and protecting access to my device and telehealth platform.

I understand that other authorized individuals (such as clinicians, supervisors, or technical staff, as permitted by law) may use the Healthie platform and are required to follow confidentiality and privacy standards.

Emergencies — Important Notice

I understand that Sunflower Clinic does not provide emergency or crisis services and that telehealth is not appropriate for emergency situations.

If I experience a medical emergency, I understand that I should call 911 or go to the nearest emergency department.

If I experience a mental health crisis or thoughts of harming myself or others, I understand that I should contact immediate crisis support, including:

I understand that telehealth may not be appropriate for all clinical situations and that my provider may recommend in-person services or a higher level of care if needed.

Consent

I confirm that I have read and understand this Telehealth Consent form. I have had the opportunity to ask questions and have received satisfactory answers. By agreeing to this consent, I voluntarily consent to participate in telehealth and teletherapy services with Sunflower Clinic under the conditions described above. I understand that I may withdraw my consent for telehealth services at any time by notifying my provider, and that withdrawal of consent will not affect my right to receive other appropriate care.